Cardio QBANK #2

___________- second-degree heart block (intermittent failure of atrial depolarization to conduct to the ventricles), which often progresses to complete (third-degree) heart block. When the patient is symptomatic, management typically requires the placement of a permanent pacemaker.

Mobitz type 2

___________- is also important to recognize, as it is a neurologic emergency. It is caused by compression of the lower lumbar and sacral nerve roots, however, and produces sensory loss in a *+saddle distribution, decreased reflexes, urinary incontinence, and flaccid and weak legs*

cauda equina syndrome

_________- gives off the common hepatic, splenic, and left gastric arteries. This artery primarily supplies blood to the colon

celiac trunk

____________-supplies the anterior surface of the left ventricle. Because this artery is a continuation of the left main artery, it will not be as impactful on survival as the more proximal disease that might occur in a patient who has left main disease. Blockage of the artery can lead to anterior wall myocardial infarction

left anterior descending artery

A 67-year-old man comes to the clinic complaining of steady, dull back pain over the past 3 weeks. He states that he has recently moved after retiring from a career in banking and is searching for a new health care provider. His past medical history is significant for diverticulosis, prior smoking, and hypertension. He says that he has run out of his blood pressure medication. He denies trauma to his back and otherwise feels well. On physical examination, his blood pressure is 170/93 mm Hg with a pulse of 88/min. He has no tenderness over the spinal processes or paraspinal areas. His abdomen is obese, but there is a suggestion of a non-tender, pulsatile mass in the epigastric region. The remainder of the physical examination is normal. Which of the following diagnoses should be considered at this time?

AAA (Abdominal Aortic Aneurysm- The combination of the history of hypertension and smoking, the new back pain, and a pulsatile mass on examination is highly suggestive for abdominal aneurysm. Additionally, he is a male older than 65 years of age, which also puts him at higher risk for AAA development.

___________- should be considered in older males, smokers, and patients who have atherosclerosis who have a palpable mass in the abdomen. It is often found incidentally when the patient has an imaging procedure on the abdomen as part of evaluation for another abdominal condition. Risk for rupture is highly dependent on the diameter of the aorta. Elective repair is recommended for males who have a >_____-cm and females who have a >____-cm diameter. Elective surgery has a much better prognosis than when Rupture Occurs

AAA, 5.5, 5 (Abdominal aortic aneurysm)

Aortic regurgitation may be helped by vasodilator therapy, which will act as afterload reducers. In addition to _________, pure vasodilators such as hydralazine and nifedipine can also be used. For patients who have ongoing symptoms who are surgical candidates, aortic valve replacement is performed when the disease decompensates

ACE (ACE inhibitor)

This patient has diabetes, hypertension, and proteinuria. Her blood pressure must be well controlled to prevent progression of nephropathy. _________ have been shown to prevent progression of diabetic nephropathy in type 1 diabetics and likely have similar preventive effects for type 2 diabetics. It should be first-line therapy for diabetic patients who have hypertension. This patient's potassium is not elevated, so this class of medications is not contraindicated.

ACE (ACE inhibitors)

_________ Meds- are useful in delaying the progression of renal disease in patients who have diabetes and in treating patients who have congestive heart failure, especially if they have impaired left ventricular function.

ACE (ACE inhibitors)

A 66-year-old woman with newly diagnosed type 2 diabetes comes to the health care provider for a blood pressure check. At a previous visit 3 months ago, her blood pressure was 140/95 mm Hg and she was advised to attempt a moderate weight loss with a low-impact exercise program and diet modification. Unfortunately her weight has increased 2 kg (4.4 lb) since her last visit. Her blood pressure is now 144/95 mm Hg. She is mildly resistant to starting medication at this time. Start on ___________

ACE (Lisinopril)

In a patient with CHF what medication will you place them on if you need to BOTH: -Decrease Preload and Afterload

ACE (captopril, enalapril, lisinopril, benazepril, ramipril)

__________- work by blocking the conversion of angiotensin I to angiotensin II in the lungs. Angiotensin II is both a potent vasoconstrictor and a stimulator of aldosterone production. Aldosterone acts by promoting sodium (and thus water) reabsorption by the kidney. An ACE inhibitor will therefore promote vasodilatation (reducing afterload), as well as reduce intravascular volume (decreasing aldosterone, as less renin is being released).

ACE (captopril, enalapril, lisinopril, benazepril, ramipril)

A 64-year-old man comes to the office for a routine checkup. He has been taking metformin (Glucophage) for his diabetes. The patient's vital signs show an elevated blood pressure, which is confirmed by his daily blood-pressure measurements at home. Urine studies show evidence of mild proteinuria. The health care provider decides to add a new medication to his regimen to treat his hypertension. What is the best class of medication to add at this time?

ACE (drug class of choice for treating hypertension in patients who have diabetic nephropathy, because they improve renal function and delay end-stage renal disease. ACE inhibitors block the angiotensin-converting enzyme in the renin-angiotensin system, causing vasodilation and increasing blood flow to the kidneys)

_________- are first-line agents for patients who have heart failure because they act as vasodilators. They decrease afterload, which allows the heart to have improvement in its ejection fraction. They do NOT have an inotropic or chronotropic effect on the heart. There is a mortality benefit demonstrated with the use of these agents.

ACE inhibitors (Beta-blockers and the aldosterone antagonist, spironolactone, also have been shown to have an improvement in mortality in patients who have chronic heart failure)

Treatment of Diastolic Heart Failure include Decreasing Risk Factors and Medications of _______ and ________ & _________

ACE, Beta Blockers and Diuretics

Patients who have stable chronic heart failure should be optimally medically managed before elective surgery being undertaken. Medical management of chronic heart failure includes (4x) to decrease secondary coronary vascular events

ACE, Beta Blockers, Diuretics and Statins

Acute onset of _________ with a rapid ventricular response is associated with hypotension. The patient may have acute deterioration that would necessitate immediate cardioversion/defibrillation. Patients need to be given volume and airway support, and management of patients in an emergency department setting is preferred. Because of the patient rapidly deteriorating, patients should be transferred to the emergency setting via emergency medical support personnel, who can intervene in case the patient becomes unstable.

AF (atrial fibrillation)

A 65-year-old patient has experienced several transient ischemic attacks over the past few months. Because his general health is poor, he is not considered an appropriate candidate for carotid endarterectomy. Examination reveals a regular rate on heart examination with a blood pressure of 130/86 mm Hg. The decision is made to treat him medically. Which of the following agents would be most appropriate for his therapy?

ASA (Daily aspirin therapy has been shown in prospective, randomized studies to reduce the incidence of stroke and death in patients who have transient ischemic attacks. If alternative therapy is needed, either because the patient cannot tolerate aspirin or because aspirin therapy has failed, the antiplatelet agent clopidogrel -Plavix- can be used)

A 75-year-old man with angina pectoris has recurrent episodes of atrial tachycardia (240/min). A rapid sequence of normal QRS waves is seen on EKG. The episodes are controllable by the patient's performance of vagal maneuvers. Which of the following is the most likely etiology of this arrhythmia?

AV Nodal Reentry (paroxysmal supraventricular tachycardia -PSVT-, which is a regular, rapid -150-250/min- arrhythmia originating in the atria or AV node. AV nodal reentry is the most common cause of this arrhythmia -about 70% of patients. In this condition, the AV node is pathologically divided into two functional pathways. The electrical impulse usually proceeds anterograde down the slow pathway and retrograde up the fast pathway. The P waves are recorded nearly simultaneously with the QRS complexes-which occur in rapid sequence- and are therefore obscured on EKG)

Paroxysmal supraventricular tachycardia (PSVT) abruptly starts and abruptly terminates. This condition can occur in the setting of coronary disease, heart failure, increased catecholamine state, digoxin toxicity, and alcohol use. Patients who have _____________ will have abrupt cessation of the tachycardia with vagal maneuvers or with the administration of adenosine (Adenocard), which temporarily stops conduction through the AV node. EKG may show P waves with RP interval caused by retrograde activation of the atria. It is the Most Common Cause of PSVT.

AV nodal re-entry tachycardia (patients who do not respond to vagal maneuvers or adenosine can be referred for an electrophysiologic test and ablation of the abnormal accessory pathway. Patients who have this abnormal accessory pathway should not have verapamil (Calan, Isoptin, Verelan) used to treat supraventricular tachycardia because of this agent's tendency to block conduction through the normal pathway, which leads to conduction only going through the abnormal re-entry pathway)

An arteriogram is performed on a patient who has atherosclerosis. Luminal narrowing of which of the following vessels would compromise blood flow through the renal arteries?

Abdominal Aorta (The renal arteries emerge from the abdominal aorta at about the level of the L1/L2 intervertebral disk and travel at nearly right angles to it-on the right, passing posterior to the inferior vena cava- to enter the hilum of the kidney)

The EKG of a 60-year-old man reveals widened QRS intervals of 0.14 seconds with distinctly abnormal configurations. Physical examination is significant for paradoxic splitting of the second heart sound. Which of the following valvular defects is likely in this patient?

Aortic Stenosis (bundle branch block, as implied by the QRS interval greater than 0.12 seconds and by paradoxic splitting of the second heart sound. The typical sequence of valve closure is mitral, tricuspid, aortic, and pulmonic. If there is a paradoxic splitting of the second heart sound, the aortic valve closes after the pulmonic valve.)

37-year-old African American man with a history of mild hypertension comes in for an annual examination. He has no complaints. He reports compliance with his low-salt diet. His only medication is hydrochlorothiazide, 25 mg each day. A thorough review of systems is negative. His temperature is 37.0°C (98.6°F), blood pressure 160/90 mm Hg, pulse 83/min, and respirations 10/min. Physical examination is within normal limits. What should be done at this time?

Add second HTN medication (Pt most likely has Essential HTN. This patient is a healthy man who is only on one medication and does not have any laboratory or physical examination. He needs a second medication at this time)

A 72-year-old woman with no prior medical history comes to the emergency department because of a 3-hour episode of crushing substernal chest pain. The pain radiates to her arm and neck. An electrocardiogram reveals ST-segment elevation in leads II, III, and aVF. The patient has no obvious contraindication to anticoagulation. Which of the following is the treatment that should be currently pursued?

Administer Thrombolytic Therapy, Heparin and ASA (Pt Having STEMI- Lysis with a thrombolytic agent has been shown to decrease mortality from early post-myocardial infarction. Aspirin prevents both platelet aggregation and reocclusion of the reperfused vessels. When aspirin and lytic therapy are given in the setting of ST-segment elevation MI, heparin is added to the regimen to stop new clots from forming. Thrombolytics given up to 75 yo)

A 16-year-old boy is brought to the emergency department by his parents because of an episode of severe chest pain several hours earlier. Review of symptoms reveals that the patient is recovering from a flu-like illness that started a week earlier. He had been complaining of fever, chills, abdominal discomfort, and feeling tired during the prior week. He has had a low-grade fever for 5 to 6 days and a sore throat, but pharyngeal swab cultures done at the primary care physician's office had been negative and he was taking over-the-counter cold medication only. Physical examination reveals a well developed and well nourished young man in moderate distress. His temperature is 37.8°C (100.0°F), pulse is 120/min, and respirations are 28/min. A differential white blood cell count shows a normal number of neutrophils and marginally elevated lymphocytes. An electrocardiogram shows low voltage QRS complexes throughout the limb leads. Chest radiography is remarkable for increased pulmonary markings and an enlarged heart silhouette. Which of the following is the most appropriate next step in the management?

Admit (signs of myocarditis and should be admitted to a monitored hospital bed for further evaluation and management. Etiology is MC Viral- Adenovirus and Coxcackie. Or Bacteria- Diptheria, rickettsia, Fungi or Parasites. Chest radiography shows an enlarged heart and pulmonary edema. Electrocardiography shows sinus tachycardia, reduced QRS complex, and abnormal S and ST waves. Echocardiography shows poor ventricular function and possible pericardial effusions, and absence of congenital heart disease and coronary artery involvement. The diagnosis is confirmed by endomyocardial biopsy. Tx- Heart Failure & Arrhythmia)

____________-decrease peripheral vascular resistance and are used in the treatment of hypertension and benign prostatic hyperplasia.

Alpha 1 Blockers

_____________- is a commonly used antiarrhythmic agent. It has efficacy in treating both ventricular and atrial arrhythmias. It is a class III antiarrhythmic under the Vaughan Williams Classification system, and has prolongation of the QT interval as a complication. Prolonged QT intervals put a patient at risk for torsades des pointes or R on T phenomena leading to ventricular tachycardia.

Amiodarone (Cordarone)

The hallmark of ____________ is sudden onset, severe chest and abdominal pain that often radiates from an anterior to posterior direction. The pain is classically described as tearing in quality. Hypertension and trauma are common precipitants for this condition.

Aortic Dissection (a common aortic catastrophe requiring admission to the hospital. This condition results from an extension of an intimal tear in the wall of the artery.)

On a routine physical examination, a midsystolic ejection murmur is detected in the pulmonic area of a 35-year-old woman. The cardiac examination also reveals a prominent right ventricular cardiac impulse and wide and fixed splitting of the second heart sound. EKG shows right axis deviation and chest radiograph shows enlargement of the right ventricle and atrium. Which of the following is the most likely diagnosis?

Atrial Septal Defect (+prominent right ventricular cardiac impulse, a systolic ejection murmur heard in the pulmonic area and along the left sternal border, and fixed splitting of the second heart sound. These findings are caused by an abnormal left-to-right shunt through the defect, creating a volume overload on the right side. The increase in volume on the right side creates the flow murmur, the dilatation of the right-sided chambers, and the delayed closure of the pulmonic valve, all of which are present in this case. The delayed closure of the pulmonic valve occurs because of the increased volume of blood that is delivered to the right ventricle.)

14-year-old boy is brought to the health care provider with decreased exercise tolerance. He is up to date on all of his childhood immunizations and has been generally healthy until now. He is noted to have a grade III/VI systolic ejection murmur best heard at the left upper sternal border and a grade II/VI mid-diastolic murmur at the lower left sternal border. The first heart sound is normal. The second heart sound is widely split and fixed. A right ventricular impulse is palpated. On a chest roentgenogram, the pulmonary artery segment is enlarged, and pulmonary vascular markings are increased. An electrocardiogram shows right axis deviation. Which of the following congenital heart diseases does this patient most likely have?

Atrial Septal Defect (One of the most common types of structural congenital heart disease to present in adolescence is atrial septal defect -ASD-, and the most common presentation is a heart murmur. Some patients, however, present with arrhythmias, decreased exercise tolerance, or a paradoxic embolus)

___________-It may not cause symptoms or it can typically present in the adolescent period. If untreated, the patient may go on to develop right atrial enlargement, cardiac arrhythmias, and heart failure. Principal features include: 1. Fixed splitting of the second heart sound 2. A midsystolic pulmonary flow or ejection murmur 3. Enlargement of the right atrium and right ventricle on imaging studies 4. On palpation, a right ventricular impulse is present

Atrial septal defect

___________- are appropriate agents in the management of angina pectoris because they decrease both heart rate and blood pressure and thus the heart's oxygen demand. They also reduce mortality in patients who have coronary artery disease and post-myocardial infarction. These agents do not prevent vasospasm, so they are NOT clinically indicated in the setting of variant or Prinzmetal angina

Beta Blockers

Widening of the P waves in lead II is associated with ____________. -This condition is often referred to as "P mitrale," as it is often associated with mitral stenosis and subsequent increased force of pressure that the left atrium has to exert to overcome this resistance.

left atrial enlargement

______________- supplies the lateral surface of the left ventricle. Damage to this artery results in a lateral wall myocardial infarction, which has some mortality associated with it but is not as life threatening as left main blockage

left circumflex artery

A 45-year-old woman comes to the emergency department complaining of recurring episodes of chest pain that each last a few minutes since she awoke this morning. She denies shortness of breath, radiation of the pain, or chest pain on exertion. She reports that she had similar episodes within the last month. The patient states that she has been healthy otherwise, takes no medications, and has no family history of coronary artery disease. Her vital signs and physical examination are within normal limits. Electrocardiogram shows transient ST-segment elevation. Serial cardiac enzymes reveal no abnormalities over a 24-hour period. Cardiac catheterization shows no significant areas of plaque or stenosis. Which of the following classes of drugs may be most effective in this patient?

CCB (Dx- Prinzmetal angina, or variant angina, is classically characterized by angina without the associated precipitating factors of angina pectoris. It is caused by a transient coronary artery spasm and displays a transient ST elevation on electrocardiogram. It usually has no other diagnostic findings. *Calcium channel blockers* have been shown to treat and prevent episodes of coronary vasospasm by decreasing contractility of cardiac muscle and producing vasodilation)

__________- may lead to pulmonary hypertension and cause elevated right-sided pressures, which may cause shortness of breath. The wedge pressure will be decreased, and the right ventricle will be dilated. The left ventricle would not be affected.

COPD

A 54-year-old man comes to his health care provider complaining of intermittent palpitations. The patient reports that a few times over the past few months he has had episodes of "pounding in his chest" that are associated with shortness of breath and occasional chest pain. He is forced to sit down if he is standing, because of weakness and vertigo. The patient has a history of hypertension and mitral valve prolapse. He takes nifedipine (Procardia, Adalat) and hydrochlorothiazide daily. While sitting in the office, the patient begins to complain of increasing shortness of breath and palpitations. His blood pressure is 85/50 mm Hg and his pulse is 110-130/min and irregularly irregular. Which of the following is the most appropriate management at this time?

Call 911 (patient has acute atrial fibrillation-AF- with rapid ventricular response-RVR- and is consequently hypotensive. This is a *medical emergency*. Even the PCP Cannot Deal with a potentially life-threatening episode of AF with RVR. Activating the emergency medical response system is always appropriate! The patient will need--> IV access, IVF, and medication or cardioversion as part of the treatment regimen. According to the Advanced Cardiac Life Support protocol, a patient who has AF with RVR who is HYPOtensive should be *cardioverted*, something that emergency medical personnel will have available to them.)

___________- of the baroreceptors will cause vagus nerve stimulation of the heart to increase, resulting in an increased parasympathetic action on the heart. This stimulation will slow the heart's conduction through the AV node. When the speed of the impulse is slowed through the antegrade pathway, it will break the reentry cycle of PSVT by slowing the antegrade pathway to a speed that approaches the speed of the retrograde pathway, thus terminating the essential requirement that the reentry dysrhythmia needs to work.

Carotid Massage

A 77-year-old man comes to the health care provider because of decreasing exercise tolerance. Just 1 year earlier he was able to play doubles tennis for 2 hours. Over the past few months, however, he has had progressive dyspnea on exertion and now can walk only 2 blocks on level ground before becoming short-winded. He has also been awaking from sleep with shortness of breath and requires 3 pillows to sleep comfortably. He has a history of rheumatic fever as a teenager. On physical examination his blood pressure is 168/60 mm Hg, pulse 92/min, and respirations 18/min. He is afebrile. He has jugulovenous distention lying supine. He has bibasilar rales extending 1/4 up both posterior lung fields. He has a regular S1 and S2, with a blowing diastolic murmur heard at the aortic area, which is grade II/VI. An S3 is audible. The liver edge is mildly tender, and there is moderate lower extremity edema extending to both knees. Which of the following medications will most likely be effective in the management of his cardiac disorder?

Catopril (ACE- physical findings of aortic insufficiency and the development of congestive heart failure with biventricular failure. Left ventricular symptoms described here are the findings of pulmonary congestion, and right-sided heart failure is demonstrated by the jugulovenous distention, congested liver, and peripheral edema. Because the "backward" failure symptoms are caused by regurgitant flow across the incompetent aortic valve, the most useful therapy would be afterload reduction with an ACE inhibitor such as captopril, which will also help to prevent cardiac remodeling as the left ventricle becomes overloaded from the increased amount volume of blood that occurs because of aortic regurgitation.)

A 57-year-old woman with a history of rheumatic fever as a child comes to the her health care provider complaining of a 6-month history of slowly progressive dyspnea on exertion and orthopnea. Her temperature is 37°C (98.6°F), blood pressure is 110/60 mm Hg, pulse is 93/min and irregular, and respirations are 18/min. Cardiac examination reveals a localized mid-diastolic murmur near the apex. There is a loud opening snap heard after S2. The rhythm appears irregular. Which of the following additional findings will most likely be present on physical examination?

Decreased S1 Intensity (patient has mitral stenosis. Most adults who have mitral stenosis have had rheumatic fever as a child, although not all patients are aware of having had this infection. Mitral stenosis decreases left ventricular filling and elevates left-sided atrial pressures. This causes pulmonary congestion and results in symptoms of left-sided heart failure, such as shortness of breath and dyspnea on exertion. Hemoptysis sometimes occurs as a result of rupture of small pulmonary blood vessels.)

After an accident at work resulting in severe hemorrhage, a machinist is rushed to the emergency department. Which of the following sets of autonomic responses would be predicted in this patient? -_______ BP -_______ Pulse

Decreased, Increased (After a decrease in blood pressure e.g., after a hemorrhage, one would expect an increase in sympathetic outflow and decrease in parasympathetic outflow. As a result of the hemorrhage, there would be less blood in the body to circulate, with resultant increase in heart rate, decrease in both blood pressure and gastrointestinal motility, and dilation of the pupils)

A 55-year-old man with hypertension and a past medical history of myocardial infarction is prescribed atenolol (Tenormin). This medication will lower his blood pressure by

Decreasing Cardiac Output (Beta Blockers- Atenolol- lower BP by both dec CO and Renin Release from Kidneys)

A 60-year-old woman with a long history of hypertension comes to the emergency department with a complaint of increasing and recurrent shortness of breath with minimal exertion. She is noted to have a prominent precordial impulse, and a chest radiograph reveals a prominent left ventricular shadow. A stress test is negative for ischemia. She is found to have left ventricular hypertrophy and a normal ventricular ejection fraction on echocardiogram. An S3 is heard on auscultation of the heart. Which of the following is the most likely underlying diagnosis causing this presentation?

Diastolic Dysfunction (Increased resistance to filling of one or more cardiac ventricles has been termed diastolic heart failure and can produce increased pulmonary capillary wedge pressures and respiratory complaints. In myocardial hypertrophy, impaired diastolic relaxation occurs. The key to differentiating systolic from diastolic types of heart failure is in the assessment of ejection fraction; it is normal and preserved with diastolic heart failure and impaired with systolic)

___________- is the clinical syndrome of heart failure, with symptoms of pulmonary and peripheral congestion in the setting of normal left ventricular systolic function (as verified with finding a normal ejection fraction). Risk factors include advancing age, female sex, hypertension, obesity, chronic kidney disease, diabetes, and coronary artery disease. Risk factor modification is the treatment of choice along with ACE inhibitors or ARBs + beta-blockers and diuretics.

Diastolic heart failure

Although _________ is a mainstay in the therapy of CHF, it has no effect on either preload or afterload. Instead it works by having a positive inotropic and negative chronotropic effect on the heart. The mechanism involves inhibition of Na+/K+ ATPase and a consequent increase in intracellular calcium, which in turn increases the heart's contractile force.

Digoxin

An elderly man presents with complaints of dizziness, headaches, diarrhea, nausea and vomiting, weakness, palpitations, and a change in vision with a yellowish to blue tint to his vision. He is taking multiple medications. He has a history of chronic heart failure and hypertension. His wife states that he has had a few episodes of confused, delirious behavior over the past few weeks. Which of the following agents might be responsible for this man's symptoms?

Digoxin (Lanoxin- )

A patient who is being treated for hypertension related to a myocardial infarction that occurred 2 hours ago is medicated with IV nitroprusside (Nipride). Which of the following is the expected action of this drug?

Dilatation of Arterioles and Venules (Nitro IV has rapid onset and used in ER & ICU. It can be titrated to effect on Drip-to-Drip basis. Nitro is on ACLS Protocol as well as Labetolol for HTN Emergency/Urgency.

__________- recommended first-line treatment for mild to moderate essential hypertension. This class of drugs decreases blood pressure by decreasing sodium, blood volume, and afterload. These drugs also provide symptomatic relief for patients who have congestive heart failure

Diuretics

A 59-year-old man with a history of myocardial infarction presents to his health care provider complaining of shortness of breath. On examination, his pulse is 110/min and his respiratory rate is 22/min. He has rales in both lung fields, a normal sinus rhythm with an S3 gallop, and 2+ pitting ankle edema. A chest radiograph reveals cardiomegaly, and his ejection fraction on echocardiogram is calculated at 37%. Which of the following medications would alleviate this patient's symptoms by significantly reducing both the preload and afterload on the heart without affecting its inotropic state?

Enalapril (Everything in this case points to congestive heart failure -CHF- dyspnea, elevated heart rate, S3, peripheral edema, and reduced ejection fraction. A drug that will alleviate the symptoms by: *decreasing both preload and afterload is necessary*)

Sx of ___________- +Roth spots are oval, pale, retinal lesions that are surrounded by hemorrhages. +Janeway lesions, which are hemorrhagic, painless, macular plaques typically located on the palms and soles, +Osler nodes, which are small, painful nodular lesions typically found on the pads of the fingers or toes.

Endocarditis

_______________- is an infection that involves the endocardial surface of the heart and includes the valves. If the patient is symptomatic, presentation includes +fever, tachycardia, and fatigue. The patient may have a new-onset heart murmur or a change in the previously heard heart murmur. Echo should be performed in all patients suspected of having this. Three sets of blood cultures should be performed to identify the pathogen. Injection drug users are at high risk for _________ infection leading to infective endocarditis.

Endocarditis, Staph Aureus (Infective endocarditis)

First-line management of *shock* is _______--> If the patient does not respond --> ________ and colloids such as albumin can be used along with vasopressors, which can help to maintain the vascular integrity and can be used to continue to stimulate the heart.

Fluids, Blood Transfusion (fluid resuscitation with crystalloids, Blood Transfusion-primarily to allow better release of oxygen to the tissues)

A 59-year-old woman comes to the health care provider because of recurrent episodes of lightheadedness upon getting up in the morning and occasionally upon standing up from a chair. She reports that on two occasions she has "passed out" soon after getting up from bed. Her temperature is 37°C (98.6°F), blood pressure is 130/80 mm Hg, pulse is 70/min and regular, and respirations are 14/min. She takes a beta-blocker and a thiazide diuretic for moderate hypertension diagnosed 6 months ago. She had rheumatic fever as a child. A thorough physical examination, including chest auscultation, is unremarkable. Which of the following is the most likely cause of this patient's symptoms?

HTN Tx ( Furthermore, measurement of orthostatic blood pressures and pulses should be performed first with the patient in a supine position, and then checked again sitting and standing. This patient's episodes of lightheadedness and syncope can be best explained as an effect of antihypertensive therapy. Orthostatic hypotension is one of the most frequent side effects of antihypertensive drugs and should always be considered in the differential diagnosis of syncope of unexplained origin)

Crush injuries such as the one sustained by this patient often result in a massive release of muscle contents. Creatine kinase (CK) is an enzyme released by dead or damaged muscle into the blood. By itself it is harmless, but it is a marker for myoglobin, which is directly nephrotoxic. Myoglobin, which is not measured by conventional assay, is released after damage to muscle. Aldolase levels can also be used to assess the degree of rhabdomyolysis. Much data exist showing early intervention with ____________ can prevent renal damage.

IV Crystalloid and Bicarbonate

A 63-year-old woman comes to the emergency department complaining of chest pain. The patient states that the pain began during her morning walk. It started as a dull pressure over her breastbone and then radiated to her left arm. Over the next few minutes, it escalated in intensity and was not relieved by rest. She called 911 and was brought to the emergency department. Her past medical history is significant for hypertension and hyperlipidemia. Her medications include atenolol and simvastatin daily. On physical examination, her blood pressure is 190/100 mm Hg, and her pulse is 60/min. Which of the following is the most appropriate agent to lower her blood pressure?

IV Nitro (Nitroglycerin is a potent vasodilator that acts predominantly on venous compliance to reduce preload to the heart. When administered intravenously, it can be rapidly titrated to produce optimized blood pressure control. IV nitroglycerin is effective when given in the setting of unstable angina)

The management of myoglobinuria includes: 1. _______ challenge to maintain urine output 1-2 mL/kg/h 2. Alkalinization of the urine: add __________ 3. Forced diuresis: add ________

IVF, Sodium Bicarb, Mannitol

A 71-year-old man comes to his health care provider for follow-up of a recent emergency department visit. The patient has a 2-year history of mild congestive heart failure in the setting of longstanding hypertension. He reports that yesterday he sought care at the local emergency department for palpitations and shortness of breath. He was told that his heart was "fibrillating," but later the fibrillation had "stopped on its own." His medications include a thiazide diuretic and an ACE inhibitor. On physical examination he appears well and in no distress. His blood pressure is 130/80 mm Hg and pulse 100/min and regular. His lungs have scant bibasilar rales and no gallops are appreciated. He has a grade 2 holosystolic murmur heard best at the apex. His jugular venous pressure (JVP) is 10 cm at 30 degrees. An electrocardiogram taken in the office reveals atrial fibrillation at a rate of 94/min with normal ST segments. Which of the following is the most appropriate next step in management?

Initiate Beta Blocker Tx

Widening of the QRS complexes in leads V5 and V6 is associated with __________ and _________. -This increased force of contraction is in sharp contrast to a patient who has impaired ventricular dysfunction caused by cardiomyopathy.

LBBB and left ventricular hypertrophy

____________- this artery has primary arterial supply to the left ventricle. Blockage of this artery leads to anterior wall and lateral wall myocardial infarction. Mortality for patients who have left main coronary artery disease is more than 10 times greater than in patients who have one- or two-vessel disease involving the other coronaries.

Left Main Artery

The mortality rate per year is greatest with disease of which coronary anatomy?

Left Main Coronary (primary arterial supply to the left ventricle. Blockage of this artery leads to anterior wall and lateral wall myocardial infarction. Mortality for patients who have left main coronary artery disease is more than 10 times greater than in patients who have one- or two-vessel disease involving the other coronaries_

_________- They act by inhibiting electrolyte reabsorption in the thick ascending loop of Henle.

Loop Diuretics (Furosemide and Ethacrynic Acid)

________-it decreases intravascular volume (and hence preload), but at typical doses it has no significant effect on either afterload or inotropic state. They are often used in the treatment of CHF, and it is used for the immediate relief of pulmonary congestion.

Loop Diuretics (Furosemide)

12-year-old African American boy is brought to the office for a well child examination. He has been in good health and only complains of an occasional headache. He has been doing reasonably well in school but has some social problems that his mother attributes to his physical appearance. She has tried persuading her son to eat healthier, but he seems to enjoy eating fast food much more than home cooked meals. His past medical history is unremarkable, and the family history is significant for adult-onset hypertension in his father's family. He takes no medication. On physical examination, the patient is in no acute distress. He is 145 centimeters tall and weighs 92 kilograms. His vital signs are within normal limits, but his blood pressure is 145/90 mm Hg. The health care provider checks that the cuff size is appropriate and remeasures his blood pressure in all four extremities, only to confirm that it is above the ninety-fifth percentile for his age. After discussing the finding with his mother, he is scheduled for several more blood pressure evaluations over the following 6 weeks. All readings yield results mildly above the ninety-fifth percentile for his age. Which of the following recommendations is most appropriate at this time? -1st _________, _______ and _______

Lose Weight, Decrease Sodium and Exercise (Dx- Systemic HTN is BP > than 95% percentile for Age on repeated measurements over 6weeks. Therapy of hypertension in children is the same as in adults: diet, exercise, and medication. Pharmacologic management includes angiotensin-converting enzyme inhibitors, calcium-channel blockers, and diuretics.)

Patients having dilated cardiomyopathy will have which of the following changes on the EKG?

Low Amplitude QRS Complex

A patient with chronic, well-compensated congestive heart failure presents with increased dyspnea and peripheral edema. Which of the following precipitating factors least likely contributes to this clinical outcome? -Start __________

Low sodium diet (is indicated in patients who have mild heart failure and may provide symptomatic improvement, especially if accompanied by periods of physical rest. Indiscriminate use of salt is one of the major precipitants for deterioration in the clinical status of a patient who has chronic heart failure. Increased sodium in the diet leads to increased water retention with an increase in the amount of intravascular volume that the patient must circulate.)

A 25-year-old man comes to the health care provider with chest pain at rest that is not always related to exercise. He reports two prior episodes of fainting during exercise but has otherwise been healthy. He reports a similar history in other family members and notes that his father suddenly collapsed and died at age 50 after playing tennis. He denies use of cocaine or other recreational drugs and does not take any medications. Physical examination reveals a systolic ejection murmur that is loudest along the left sternal border. The rest of the physical examination is unremarkable. Echocardiography shows asymmetric septal hypertrophy without obstruction. Which of the following interventions would be most likely to decrease this patient's systolic murmur?

Lying Down (pt has Hypertrophic Obstructive Cardiomyopathy- The systolic ejection murmur is diminished when the patient lies down, because this maneuver increases cardiac size by increasing venous return and tends to diminish the intensity of the murmur. Afterload is increased, and venous return is increased to the heart. This increases the ventricular size and diminishes the murmur.)

Which of the following medications is the most appropriate choice for the treatment of hypertension during pregnancy?

Methyldopa (alpha 2 agonist, decrease BP by Decreasing Peripheral Vascular Resistance. *Drug of Choice for Tx HTN during Pregnancy that may lead to Pre-Eclampsia.)

A 57-year-old man comes to his health care provider for a preoperative evaluation. He has been a long-time patient in this office and has been treated for hypertension and gastritis. He has been scheduled for an elective cholecystectomy in 2 days because of ongoing gallbladder symptoms. He currently takes omeprazole (Prilosec) for his gastritis and thiazide for his hypertension daily. He smokes two packs of cigarettes per day. His home blood pressure log shows that his systolic pressures range from 150 to 190 mm Hg, and his diastolic pressures range from 80 to 105 mm Hg, indicating that his blood pressure may be not adequately controlled for the surgical procedure. Which of the following medications is most appropriate in the perioperative period for added blood pressure control?

Metoprolol (extensive body of literature indicating that beta-blockers given to non-cardiac surgical patients who are at risk for cardiac events are associated with a more favorable outcome in terms of postoperative cardiovascular morbidity and mortality. This patient has somewhat poorly controlled hypertension, as well as at least three cardiovascular risk factors -hypertension, tobacco, age. Ideally one would like to have better control of the blood pressure and to reduce any risk for adverse perioperative events before the patient has elective surgery. Beta-blockers can achieve both of these endpoints. Beta Blockers may have utility in the perioperative setting because of their cardiac morbidity benefit)

On physical examination of a patient, the health care provider hears a rumbling mid-diastolic murmur with an opening snap heard best at the apex of the heart. What is the most likely explanation for this finding?

Mitral Stenosis

_________- second-degree heart block: progressive lengthening of the PR interval with successive heartbeats, culminating in a nonconducted atrial depolarization. This particular type of heart block is benign and does not require therapy.

Mobitz type 1 (Wenckebach phenomenon)

_____________- is inflammation of the myocardium without acute or chronic ischemia. It is a clinical syndrome of nonischemic myocardial inflammation resulting from a heterogeneous group of infectious, immune, or nonimmune diseases. Histologically, it is characterized by an inflammatory cellular infiltrate *without evidence of myocyte injury*. Systemic corticosteroids may be helpful with inflammatory and autoimmune myocarditis. Treatment of the underlying cause is helpful if a cause can be found.

Myocarditis

A 32-year-old woman comes to the hospital for an elective repeat cesarean delivery. Four years ago she had a primary cesarean delivery for a nonreassuring fetal heart rate tracing. Two years ago she chose to have an elective repeat cesarean delivery rather than attempt a vaginal birth after cesarean (VBAC). Her prenatal course was uncomplicated except that she has mitral valve prolapse. An echocardiograph demonstrated the mitral valve prolapse but no other structural cardiac disease. Which of the following is the correct management of this patient specifically as related to her mitral valve disease? Are ABX Needed?

NO (Consequently the issue of mitral valve prolapse and the need for antibiotics is frequently debated.)

_________ and ________- are parenteral agents indicated for treating hypertensive urgency and hypertensive emergency. They may also be used to treat hypertension that is related to sympathomimetic drug use (such as cocaine, amphetamines, phenylpropanolamine, MAO-related hypertensive crisis). As a potent arterial and venous dilator, it is able to reduce both preload and afterload. It is typically administered with a beta-blocker, because its potent nitroprusside-induced vasodilation induces a strong compensatory tachycardia that might increase stress to the system.

Nitro and Labetolol (Sodium nitroprusside and Labetolol)

A 61-year-old man is brought to the emergency department for chest pain. The patient has a long history of coronary artery disease and is status post-coronary bypass procedure 6 years ago. The patient has chronic stable angina that is usually precipitated by activity and relieved by rest. About 3 weeks ago, his health care provider prescribed sildenafil (Viagra), and he has been using the drug with success. This morning he developed acute onset of substernal chest pain radiating to his left arm. This pain is not relieved by rest. The patient last took a sildenafil (Viagra) the night before. Which of the following treatments is absolutely contraindicated in this situation?

Nitroglycerin (CONTRAINDICATED to take Nitro within 24hrs of Sildenafil/Viagra!The vasodilatory effects of nitrates are profoundly amplified when administered in the presence of sildenafil, which can lead to refractory and life-threatening hypotension and cardiovascular collapse because of a synergistic effect. Patients using sildenafil therefore should be instructed to report their use on presentation to any emergency department and to never take nitrates while using the drug.)

___________- is a regular, rapid (150-250/min) arrhythmia originating in the atria or AV node. *AV nodal reentry* is the most common cause of this arrhythmia (about 70% of patients). In this condition, the AV node is pathologically divided into two functional pathways. The electrical impulse usually proceeds anterograde down the slow pathway and retrograde up the fast pathway. The P waves are recorded nearly simultaneously with the QRS complexes (which occur in rapid sequence) and are therefore obscured on EKG. This arrhythmia is commonly seen in older patients, about half of whom have underlying heart disease. Tx- Vagal Maneuvers

PSVT (paroxysmal supraventricular tachycardia )

__________- can improve perfusion of vital organs and reduce the workload of the heart because it is both an arteriolar and venodilator. Problems sometimes encountered with this drug include hypotension (best avoided by starting with a low dose and continuously monitoring systemic arterial and pulmonary capillary wedge pressures) and accumulation of toxic metabolite (thiocyanate) of cyanide in patients who have liver or renal failure.

Nitroprusside

Which of the following best describes why carotid sinus massage will result in the slowing of PSVT along with return of the patient to normal sinus rhythm?

PSVT is caused by a reentry circuit that involves the AV node, and vagal stimulation from this maneuver will stimulate the vagus nerve to break the reentry cycle.

_________-It is freely filtered at the glomerulus and is not reabsorbed. Its primary action occurs at the proximal tubule.

Osmotic Diuretic (Mannitol)

A 2-month-old baby boy is brought to the clinic by his mother for a routine checkup. On physical examination, the health care provider hears a continuous machinery murmur near the left sternal border at the second interspace. What is the most likely diagnosis?

Patent Ductus Arteriosus

A 16-year-old boy is brought to the urgent care clinic with a temperature of 38.4°C (101°F) and low back, wrist, and knee pain. He had a sore throat 1 month earlier. His arthritis is diffuse. Pea-sized swellings are noted over the skin on his knees. He has a serpiginous erythematous area on his anterior trunk. His blood and throat cultures are negative, and his CBC is unremarkable. His antistreptolysin-O (ASO) titer is high. Which of the following is the most appropriate therapy?

Penicillin and ASA (Pt has Acute Rheumatic Fever from Group A Strep + other sx- PCN for Infection and ASA for Pain relief)

Rheumatic fever is treated with _______ (for the bacterial infection) and _______ (for the arthralgias). Remember, ________ is NOT indicated in viral infections because of the potential to *cause Reye syndrome*. Penicillin that is given within 9 days of infection is most likely to prevent rheumatic fever.

Penicillin and ASA, ASA

A 43-year-old woman comes to the health care provider with a several-month history of dyspnea on exertion. She denies chest pain or a family history of coronary artery disease. She has a history of rheumatoid arthritis. Chest radiograph is remarkable for calcification of the heart border on the lateral film. She appears to have constrictive pericarditis. Which of the following physical examination findings would most likely be expected in this patient?

Pericardial Knock (constrictive pericarditis, the lateral view of the chest may demonstrate calcification of the anterior pericardium. This may be seen in 50% of patients who have longstanding constriction. The pericardial thickening may be seen on an echocardiogram. A pericardial knock is heard after the aortic valve closes, which is caused by the sudden cessation of ventricular filling)

A 1-week-old baby girl has a coarctation of the aorta just distal to the subclavian arteries. The blood pressure distal to the constriction is 50% lower than normal. Which of the following is increased in this infant?

Plasma Levels of Renin (aorta is constricted at a point beyond the arterial branches to the head and arms but proximal to the kidneys. Collateral vessels in the body wall carry much of the blood flow to the lower body, and the arterial pressure in the lower body is about 50% lower compared with the pressure in the upper body. The lower than normal pressure at the level of the kidneys causes renin to be secreted with the eventual conversion to angiotensin I and angiotensin II. The renin-aldosterone system results in salt and water retention, so that within a few days to weeks the arterial pressure in the lower body (at the level of the kidneys) increases to normal, but in doing so, the blood pressure in the upper body has increased to hypertensive levels)

____________-It acts on the collecting tubule to inhibit the reabsorption of Na+ and the secretion of K+.

Potassium Sparing Diuretic (Triamterene and Amiloride, but Spironolactone is an aldosterone antagonist that binds to its receptor.)

Which of the following diuretic agents is most likely to cause hyperkalemia?

Potassium Sparing Diuretics (Triamterene, Spironolactone, amiloride)

___________- is a cardiac condition that is primarily caused by vasoconstriction or coronary artery disease. These patients may have *transient ST-segment elevation* during the painful episode. *Cardiac enzymes remain normal*. Treatment consists of _______, which may be used to prevent or treat cardiac vasospasm. Lifestyle modifications should be used in all patients.

Prinzmetal angina, CCB (or Variant Angina)

A 61-year-old woman comes to the health care provider for her first physical examination in more than 10 years. She reports that she has been in excellent health, does not smoke or drink, and runs 3 miles daily. She is a retired accountant and has 3 healthy grown children. She has been taking 81 mg of aspirin daily after reading about its cardioprotective effects in the newspaper. On physical examination she appears well. Blood pressure is 122/76 mm Hg, pulse 70/min, and respirations 14/min. She is afebrile. Head and neck examination is normal. There is no jugulovenous distention. Lungs are clear. On cardiac examination she has a regular S1 and S2, and II/VI crescendo blowing diastolic murmur is heard at the aortic area. Abdominal examination is normal. Rectal examination shows no masses and brown, guaiac-negative stool. Which of the following most likely explains the cardiac findings on physical examination?

Prior Strep Infection (findings of asymptomatic aortic insufficiency on physical examination. This lesion may result from a number of causes, several of which are infectious in etiology. Aortic insufficiency may result as a sequela of rheumatic heart disease, which occurs as an immunologic response to a streptococcal infection. Acute rheumatic fever is typically characterized by cardiac involvement that may cause pericarditis, myocarditis, or endocarditis. Often the initial cardiac manifestations are asymptomatic and become apparent only years later with the development of cardiac valvular disease)

__________- is defined as a fall in systolic blood pressure >10 mm Hg on inspiration. It can be associated with cardiac tamponade and chronic obstructive pulmonary disease (COPD).

Pulsus Paradoxus

A woman is brought into the emergency department following an automobile accident in which her chest was hit by the steering wheel. Her blood pressure is 120/90 mm Hg. When she inhales, her systolic blood pressure drops to 100 mm Hg. This finding defines which of the following terms?

Pulsus Paradoxus ( is defined as a fall in systolic blood pressure >10 mm Hg on inspiration. It can be associated with cardiac tamponade and COPD)

___________- is a repeated variation in the amplitude of the pulse pressure. It can be associated with profound left ventricular dysfunction.

Pulsus alternans

__________- is a double pulsation occurring during systole. It can be associated with aortic regurgitation and hypertrophic cardiomyopathy.

Pulsus bisferiens

__________- is a weak pulse upstroke caused by diminished stroke volume. It can be associated with hypovolemia, aortic stenosis, mitral stenosis, and left ventricular failure.

Pulsus parvus

__________- is a delayed pulse upstroke. It can be associated with aortic stenosis

Pulsus tardus

A 40-year-old woman is brought to the emergency department following a suicide attempt with imipramine (Tofranil). Her fiancé found her unresponsive, with an empty bottle of the imipramine at her side. The imipramine had been his, and the prescription had been filled that morning. Her past medical history is significant for hypertension, atrial fibrillation, diabetes, and asthma. Her medications include furosemide, procainamide, glyburide, prednisone, and albuterol. She has no known drug allergies. She is afebrile, has a blood pressure of 100/60 mm Hg, pulse of 62/min, and respirations of 22/min. A gastric lavage yields multiple pill fragments. She is confused and somnolent, and has shallow respirations. Her physical examination is otherwise unremarkable. On an electrocardiogram, which of the following abnormalities would most likely reflect possible cardiac toxicity?

QT Prolongation (prolongation of the QT interval is highly predictive of both cardiac and CNS toxicities from tricyclic antidepressant ingestion. This medication has high lethality associated with its overdose because of its cardiac effects)

A 70-year-old hypertensive man arrives at the emergency department complaining of shortness of breath. His history is significant for chronic hypertension, paroxysmal nocturnal dyspnea, and nocturia. Physical examination reveals evidence of pulmonary and peripheral edema. The patient is admitted, and furosemide is administered. A low-sodium diet is ordered. The purpose of this dietary restriction is to -_______ ________ water

Reduce Extracellular

-Acute glomerulonephritis, transplant rejection are examples of ________ causes of oliguria. -Bladder tumor and prostatic hyperplasia are examples of ________ causes of oliguria.

Renal, postrenal

____________- a phosphodiesterase inhibitor, is used to enhance the effects of nitric acid, which increases cyclic GMP. This effect is useful to treat erectile dysfunction. This class of medication is strictly contraindicated for use with nitrates and protease inhibitors (class of medications used in the management of HIV and AIDS). If used together, significant hypotension and even cardiovascular collapse may occur. These agents cannot be used within 24 hours of the last dose of either of these agents

Sildenafil (Viagra)

A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8-cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest radiograph is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time his blood pressure was high, for which he declined treatment. Which of the following is the most likely diagnosis?

Rupture of Abdominal Aortic Aneurysm (reach or exceed a size of 5.5 cm in males and 5.0 cm in females. Often the first manifestation is excruciating back pain, as the blood leaks into the retroperitoneal space before the aneurysm blows out into the peritoneal cavity. The combination of a big pulsatile mass and sudden severe back pain should always lead to this presumptive diagnosis. Looking for orthopedic or neurologic explanations can be a deadly mistake. In any patient who has a rupturing aneurysm or who is hemodynamically unstable, immediate surgical intervention is required)

This hypertensive patient has symptoms and signs of congestive heart failure (paroxysmal nocturnal dyspnea, nocturia, and pulmonary and peripheral edema), for which dietary ______ restriction is recommended to reduce water retention.

Sodium

A 29-year-old man is brought to the emergency department in a comatose state a few hours after complaining of sudden onset of excruciating headache. His friend does not know if the patient has any underlying medical conditions. Neurologic examination reveals dilated pupils poorly responsive to light. A CT scan of the head without contrast demonstrates hyperdensity within the suprasellar cistern, whereas MRI scan is unremarkable. Lumbar puncture shows hemorrhagic cerebrospinal fluid. Which of the following is the most likely diagnosis?

Ruptured Berry Aneurysm (Rupture of a berry aneurysm is the most common cause of subarachnoid bleeding.Berry aneurysms develop as a result of congenital weakness at branching points of the arteries in the circle of Willis. These outpouchings tend to expand progressively, but in most cases they remain asymptomatic. Hypertension facilitates development and rupture of berry aneurysm. One third of patients recover, one third die, and one third develop re-bleeding. Rapid onset of coma is an ominous sign.)

___________- should be considered in hypertensive patients who present either at extremes of age or who have other clinical symptoms that point toward a certain etiology. It may also be suspected in patients with hypertension that is difficult to control or who have to take multiple medications for hypertension control. In otherwise healthy patients, attempts should be made to control blood pressure with diet and medications before considering other causes.

Secondary HTN

A 52-year-old man is discharged from the hospital after an uncomplicated myocardial infarction. Several weeks later, he visits his primary care provider complaining of insomnia, anorexia, and depressed mood. He appears to be clinically depressed. He denies any current chest pain or shortness of breath. Which of the following would be the most appropriate medication to initiate for this patient?

Sertraline (Zoloft- pt who has cardiac complications SSRI has been demonstrated to be the SAFEST and Most Effective Med for Tx of Clinical Depression)

A patient having _______ will have decreased perfusion to the kidneys. This decreased perfusion will cause the kidneys to compensate for this impaired blood flow by increasing the release of renin, which will then lead to the formation of angiotensin I, which gets converted to angiotensin II, and later conversion to aldosterone occurs. This will result in *vasoconstriction and retention of sodium*, which will retain water and conserve water loss from the body.

Shock (The urine in these patients will have a low fractional excretion of sodium, which will be <1%. This low fractional excretion of sodium will help to preserve fluid in this shock state, which will permit more volume being available for the body to use.)

Which of the following is an example of a prerenal cause of oliguria?

Shock (not all oliguria is caused by intrinsic renal disease. Shock, of any etiology, is an example of a prerenal cause of oliguria in which poor renal perfusion leads to inadequate urine output.)

A 63-year-old retired airline pilot comes to the office for a first time visit. He is switching primary care facilities because he was very unhappy with the care that he previously received. He brings his medical record, which documents longstanding cirrhosis and portal hypertension caused by previous alcohol abuse. He has no history of gastrointestinal bleeding. He has a very long medication list, and he reports that his pharmacist told him that his medications "were wrong" and that his health care provider was prescribing drugs improperly. On review of his medication list, a number of medication incompatibilities are found. Co-administration of which of the following is likely to cause this patient the greatest harm if not corrected?v

Spironolactone and Oral Potassium (Spironolactone is a potassium-sparing diuretic. The mistake of calling this drug a "diuretic" and cueing your brain to think "replenish electrolytes" could cause this patient to die from hyperkalemic cardiac arrest. Spironolactone is increasingly used as an add-on agent for chronic heart failure, as there has been mortality benefit demonstrated with its use. Spironolactone also is a direct aldosterone antagonist and can be beneficial in the setting of cirrhosis with ascites, to lessen fluid accumulation)

A 22-year-old man comes to the emergency department with a 3-day history of fever, chills, a cough, pleuritic chest pain, and low back pain. He says that the symptoms came on "out of the blue." He is the son of a wealthy local businesswoman and still lives at home, which he says "is cool because my parents are never around." His temperature is 39°C (102.2°F), blood pressure 120/80 mm Hg, pulse 70/min, and respirations 16/min. Physical examination shows oval retinal hemorrhages with a clear, pale center and pinpoint lesions between his toes. Blood cultures are drawn. A chest radiograph shows multiple patchy infiltrates. Laboratory studies show hemoglobin 11 g/dL, hematocrit 39%, and erythrocyte sedimentation rate 39 mm/h. Which of the following is the most likely pathogen?

Staph aureus (This patient has acute bacterial endocarditis, most likely caused by Staphylococcus aureus, the most common organism causing endocarditis in intravenous drug abusers. The "pinpoint lesions" between his toes are signs of injection drug abuse. Acute endocarditis in drug abusers typically presents with a high fever, pleuritic chest pain, and a cough. The tricuspid valve is commonly affected in these patients)

A 45-year-old woman has a history of symptomatic ventricular couplets, for which she had been placed on amiodarone (Cordarone). A week after this intervention, she experiences a syncopal episode and is brought to the emergency department. The patient is awake and alert with a blood pressure of 110/70 mm Hg and pulse 90/min. Electrolytes are within normal limits. She is placed on a cardiac monitor and is noted to have a transient wide complex tachycardia with waves of alternating morphology. She appears to be in torsades de pointes. Which of the following is the most appropriate next step?

Stop Amiodarone and Observe (diagnosed with polymorphic ventricular tachycardia called torsades de pointes. This can be a fatal rhythm and is associated with a prolongation of the QT interval, which could have occurred as a result of the amiodarone administration. The appropriate step is thus to discontinue the amiodarone and observe)

A 67-year-old woman comes to the clinic for review of her medications. She has had a history of hypertension for 25 years, type 2 diabetes for 20 years, and congestive heart failure for 5 years. She is a former smoker of two packs of cigarettes per day and her lipid status is not known at this time. Her current medications include nifedipine (Adalat, Procardia), hydralazine (Apresoline), isosorbide dinitrate (Isordil), glyburide (DiaBeta, Micronase), a multivitamin, and conjugated estrogens. Today in the clinic her blood pressure is 160/90 mm Hg, her fasting blood glucose is 210 mg/dL, and her hemoglobin A1c is 7.9%. She reports moderate dyspnea on exertion, unchanged from previous visits. Which of the following is the most appropriate intervention at this time?

Stop Hydralazine and Add Captopril (Pt has poorly controlled HTN and DM. She needs improved therapy for both; the issue is how best to do that. The concept underlying this question is the absolute importance of using ACE inhibitor therapy on both type 1 and type 2 diabetic patients. Many clinical trials have shown the beneficial effects of ACE inhibitors on preventing nephropathy and slowing the progression of established nephropathy in diabetics. It is the standard of care that all diabetics be given an ACE inhibitor if they are able to tolerate its blood pressure effects. Given that she has congestive heart failure and hypertension, the ACE inhibitor also will be efficacious in their treatment. In fact, ACE inhibitors have been shown to be superior to hydralazine and isosorbide dinitrate in terms of morbidity and mortality in treatment of CHF)

A 10-year-old girl is brought to the office because of fever and chills for 3 days. She had been complaining of a headache and feeling tired for 10 days before she developed fever. The parents had tried giving her acetaminophen, but the child's condition was not improving. Her past medical history is significant for frequent streptococcal throat infections over the past 2 years and a new onset heart murmur detected at her last well child visit 2 months earlier. She is on no medication currently, except for acetaminophen. Otherwise, she has been wearing dental braces for the past year and had a primary tooth extracted 2 weeks earlier in the attempt of liberating space for permanent teeth. On physical examination, the patient is diaphoretic, in moderate distress with a temperature of 39.0°C (102.2°F), blood pressure of 90/60 mm Hg, pulse of 110/min, and respirations of 24/min. On her fingernails, you note several splinter hemorrhages. Auscultation confirms a grade 2/6 high-pitched, blowing, systolic ejection murmur, best heard at the apex that radiates to the left axilla. A chest radiograph is unremarkable, but the electrocardiogram shows signs of left ventricular strain. An echocardiogram reveals vegetations on the mitral valve. Which of the following microorganisms is the most likely cause of this patient's current condition?

Strep Viridans (developed acute endocarditis most likely caused by Streptococcus viridans that entered the bloodstream during the recent dental procedure. The predisposing factor for her current illness is rheumatic heart disease, a sequela of prior Group A β-hemolytic streptococcal pharyngitis, which was complicated by involvement of the mitral valve.)

Rupture of a berry aneurysm is the most common cause of ___________________. Berry aneurysms develop as a result of congenital weakness at branching points of the arteries in the circle of Willis. These outpouchings tend to expand progressively, but in most cases they remain asymptomatic. Hypertension facilitates development and rupture of berry aneurysm. One third of patients recover, one third die, and one third develop re-bleeding. Rapid onset of coma is an ominous sign.

Subarachnoid Hemorrhage

A 25-year-old woman involved in an automobile accident is admitted as an emergency patient. A major artery severed in her leg caused an estimated 600 mL blood to be lost. Her blood pressure is 90/60 mm Hg. Which of the following would be expected to increase in response to hemorrhage?

Sympathetic Nerve Activity (decrease in blood pressure caused by hemorrhage activates the baroreceptor reflex, which tends to increase sympathetic nerve activity and decrease parasympathetic vagal nerve activity)

___________- +pulmonary edema, normal neck veins, lack of edema in extremities, or a hepatojugular reflex and a abnormal ejection fraction.

Systolic Heart Failure (Ventricular Fxn Impaired)

A 5-month-old girl is brought to the office by her mother, who states that the girl had an episode following feeding during which she began to breathe deeply, became blue, and then lost consciousness. The mother states that she picked her up and held her, and the infant regained her usual color and became alert. Physical examination reveals a harsh systolic murmur. The remainder of the physical examination is unremarkable. Which of the following is the most likely diagnosis?

Tetralogy of Fallot

___________- can present with cyanotic spells associated with feeding and/or crying. Episodically there can be near-occlusion of the right ventricular outflow tract with profound cyanosis. These episodes are often referred to as "tet spells" or "hypercyanotic spells."

Tetralogy of Fallot

____________- It is the most common type of cyanotic congenital heart disease.

Tetralogy of Fallot

A 15-month-old boy is brought to the emergency department by his parents because he suddenly turned blue and had difficulty breathing while he was playing in the back yard of their home. The parents have noticed several times in the previous 2-3 months that he had developed a bluish discoloration around the lips but did not think much of it, as it was wintertime. Recently, however, the boy had increasing fatigability and would stop in the middle of playing to catch his breath by sitting down or squatting. This morning when he suddenly turned blue and started behaving in a very flustered manner they rushed him to the emergency department. The parents deny any other significant medical conditions or allergies to medication. They have a 4-year-old daughter who is in good health. On physical examination, the patient is in the fifth percentile for height and weight. His lips and fingertips are bluish in color and he frequently stops to catch his breath while playing in the examination room. There is a hint of clubbing of his fingers. Vital signs are within normal limits, but a complete blood count shows a red blood cell count of 6 x 1012/L and a hematocrit of 66%. A chest radiograph shows a boot-shaped heart with an uptilted apex and clear lung fields. On auscultation, there is a harsh systolic ejection murmur and a single S2 is heard. Which of the following is the most likely diagnosis?

Tetralogy of Fallot (defined as pulmonary stenosis, ventricular septal defect, dextroposition of the aorta (overriding), and right ventricular hypertrophy. It is the most common type of cyanotic congenital heart disease)

_____________- Typically, patients present with cyanosis, delayed growth and development, and dyspnea. Paroxysmal hypercyanotic attacks (hypoxic, blue, or tet spells) manifest with episodes of restlessness, cyanosis, and gasping respirations. Clubbing of the fingers and toes occurs secondary to chronic hypoxia. A loud, harsh, systolic ejection murmur is heard. S2 is single or very soft because of the pulmonary stenosis. Chest radiographs reveal a boot-shaped heart (coeur en sabot) with uptilted apex.

Tetralogy of fallot

Which of the following diuretics acts at the distal tubule of the nephron?

Thiazide Diuretics (Hydrochlorothiazide, Chlorothiazide, Benzthiazide- promote Diuresis by inhibiting Reabsorption of NaCl, primarily in the Early Distal Tubule)

_________- promote diuresis by inhibiting reabsorption of NaCl, primarily in the early distal tubule

Thiazide Diuretics (e.g., hydrochlorothiazide, chlorothiazide, benzthiazide)

A 59-year-old man chooses a health care provider. The health care provider discovers that the patient was recently admitted to the hospital for palpitations and was found to have newly diagnosed atrial fibrillation (AF). He was placed on digoxin (Lanoxin) and verapamil (Calan, Isoptin, Verelan) for rate control and was loaded with warfarin (Coumadin) for anticoagulation. After several trips to the anticoagulation clinic, he decided to stop taking his warfarin, as it was difficult for him to leave work during the day. He now calls the office complaining of a cold, pale, and painful right leg starting an hour ago. Which of the following is the most likely explanation for his symptoms?

Thromboembolism (Overall, atrial fibrillation confers about a 1% annual risk for a thromboembolic event, which, among other things, may cause stroke, intestinal ischemia, renal infarcts, or a threatened limb. Specific etiologies of AF such as valvular disease are associated with higher rates of embolic events.- NO DVT! This is an Arterial problem from thromboembolism)

A 35-year-old woman presents to her health care provider with paresthesias of the left shoulder and arm. She has also noticed a hard, bony structure on the left side of her neck above the clavicle. Which of the following diagnoses best accounts for her symptoms?

Thoracic outlet syndrome (patient has a left cervical rib. This anatomic variant, which is typically bilateral but can occur on only one side, is caused by formation of an extra rib at the C7 level. Cervical ribs, while often asymptomatic, can cause thoracic outlet obstruction. This results in pain caused by distortion of blood vessels; pain or paresthesias related to brachial plexus impingement -notably sensory disturbances in the distribution of the ulnar nerve-, and palpable abnormalities in the greater supraclavicular fossa.)

The congenital form of _______ aneurysm formation has an association with polycystic kidney disease, Marfan disease, Ehlers-Danlos syndrome, and neurofibromatosis.

berry (congenital weakness at branching points of the arteries in the circle of willis)

_________________- occurs as a result of compression of one or more neurovascular structures in the superior portion of the chest. Presence of a cervical rib is a known risk factor for this condition. If the nerve is compressed, the patient will have paresthesias and motor weakness along with pain in the affected dermatome. Physical stress will worsen these symptoms, and the Adson maneuver can be used as part of the assessment for this condition. Treatment may consist of physical therapy with core strengthening. Surgical correction of the anatomic abnormality is used if conservative therapy fails.

Thoracic outlet syndrome

Headache of sudden onset ("thunderclap" headache), rapid deterioration of mental status, and blood in the CSF are virtually diagnostic of ruptured ____________.

berry aneurysm

____________- is a polymorphic ventricular tachycardia with a twisting morphology that can result in a fairly normal cardiac output or a hemodynamically compromised situation. IV magnesium sulfate may play a role in the management of it provided that the patient is magnesium deficient. If pt is on __________ should be withdrawn as part of the treatment regimen and any underlying electrolyte abnormalities should be corrected.

Torsades, Amiodarone

A 72-year-old man is scheduled to have elective sigmoid resection for diverticular disease. He has a history of heart disease and had a documented myocardial infarction 2 years ago. He currently does not have angina, but he lives a sedentary life because "he gets out of breath" if he exerts himself. Physical examination reveals jugular venous distention. His hemoglobin level is 9 g/dL (normal 14-17 g/dL in men). If surgery is indeed needed, which of the following should most likely be done prior to the operation?

Treat for CHF (Jugular venous distention in this setting is indicative of congestive heart failure, a condition that would make elective surgery very risky. Medical treatment for congestive heart failure can reduce the risk. This patient has right-sided heart failure, which is most commonly caused by left-sided heart failure)

___________- causes stimulation of the vagus nerve. One way to perform is by straining down to defecate, carotid massage, eyeball pressure, and putting the face in cold water. -The *Vagus Nerve* is responsible for putting on the breaks in the conduction through the AV Node and decrease SBP by 50mmHg or Sinus Pause for 3 seconds

Valsalva Maneuver

A man complains to his health care provider that he feels lightheaded and has even fainted during defecation. This is most probably an example of syncope due to which of the following mechanisms?

Valsalva Maneuver (Syncope has a broad differential diagnosis, because fainting can be produced by a wide variety of mechanisms. All of the mechanisms listed in the answers can produce syncope, but only the Valsalva mechanism (in which high intra-abdominal pressures trigger a reflex fall in cardiac output from vagal stimulation) is specifically associated with defecation. This mechanism can also produce fainting during weightlifting and with the use of wind instruments.)

Tetralogy of Fallot has the following components: (1) _________ septal defect, (2) overriding aorta, (3) ______ _______ hypertrophy, (4) ___________ stenosis.

Ventricular, Right Ventricular, Pulmonic

A 62-year-old man comes to the health care provider with symptoms of worsening congestive heart failure. He has a history of rheumatic heart disease as a child. Over the past 3 years he has had progressive symptoms of dyspnea on exertion, paroxysmal nocturnal dyspnea, and orthopnea. He has been maintained on digoxin, furosemide, and enalapril for symptoms of his congestive heart failure. Cardiac examination reveals a loud blowing decrescendo diastolic murmur. He has bounding peripheral pulses. Which of the following additional findings would most likely be found on physical examination?

Wide pulse pressure (aortic insufficiency, including the loud blowing decrescendo murmur and the bounding peripheral pulses. These patients typically will have a wide pulse pressure (i.e., elevated systolic blood pressure) related to a large left ventricular volume being ejected (until left ventricular failure supervenes). The low diastolic pressure is a result of the rapid run-off from the aorta caused by the regurgitant flow across the aortic valve into the left ventricle as well as the forward flow to the aorta.)

Pt diagnosed with polymorphic ventricular tachycardia called torsades de pointes. This can be a fatal rhythm and is associated with a prolongation of the QT interval, which could have occurred as a result of the __________ administration for symptomatic ventricular couplets. The appropriate step is thus to discontinue the Med and observe

amiodarone

______________- correlates well with the duration of the murmur (not the intensity of the murmur). Other physical findings seen with it include: +water hammer pulse +soft or absent A2-caused by inadequate closure of the valve +displaced, hyperdynamic apical impulse +de Musset sign-head bobbing with each heart beat, +Muller sign- pulsation of the uvula, +Traube sign- pistol shot sounds over the femoral artery with compression

aortic regurgitation

Increased resistance to filling of one or more cardiac ventricles has been termed ____________ and can produce increased pulmonary capillary wedge pressures and respiratory complaints.

diastolic heart failure

The collection of symptoms described—dizziness, headaches, diarrhea, nausea and vomiting, weakness, palpitations, and a change in vision with a yellowish to blue tint to the vision—are classic side effects of _______. EKG changes, such as biventricular tachycardia, may also occur. It is a medication that has been shown to improve symptoms in patients who have heart failure, as it is a positive inotropic and negative chronotropic agent. Patients who are hypokalemic are especially prone to the development of TOXICITY!

digoxin (Lanoxin)

The key to differentiating Systolic VS Diastolic types of heart failure is in the assessment of _________ -Normal and preserved with _______ heart failure -Impaired with _________.

ejection fraction, Diastolic, Systolic

Increased voltage in the chest leads is associated with _________ -Because the EKG measures electrical activity, it will have increased amplitude of the R wave from the increased force of contraction

hypertrophy of the left or right ventricles

Shock is a clinical condition in which there is inadequate organ perfusion and tissue oxygenation. It is classically associated with -____tension -____cardia -____pnea.

hypo, tachy, tachy (The normal physiologic response to shock is to have sympathetic release of hormones, which will stimulate the heart to beat faster and stronger so that the volume of blood can be circulated faster and with more force to overcome the deficiency of the blood supply to the end organs and to improve perfusion.)

___________ artery- gives off the superior rectal, sigmoid, and left colic arteries. Occlusion to this artery causes acute bowel ischemia

inferior mesenteric

The signs of acute arterial embolism include the "6 Ps": +__________

pain, pallor, paresthesias, paralysis, pulselessness, and poikilothermia

A continuous machinery murmur is characteristic of _________________

patent ductus arteriosus (PDA- also characterized by bounding pulses with wide pulse pressure.)

The majority of diuretics used in clinical practice result in hypokalemia and hyponatremia because of the loss of these electrolytes as part of their clinical utility in causing diuresis. The ____________- inhibit distal convoluted tubule aldosterone-induced sodium resorption, which permits sodium loss and potassium retention. Although they cause weak diuresis, there is evidence showing that there is mortality benefit when these agents are used as add-on agents for chronic heart failure.

potassium-sparing diuretics (Triamterene, Spironolactone, amiloride- *CAUTION w/ Impaired Renal Fxn w/ ^K+)

__________- supplies blood to the right ventricle and posterior surface of the left ventricle. Blockage of this artery may result in right ventricular infarct, inferior wall, or posterior wall myocardial infarction. This myocardial infarction pattern needs to have volume support. Because the majority of patients have the artery supplying the AV node, heart block may occur with blockage of this artery.

right coronary artery

___________ artery- gives off the inferior pancreaticoduodenal, intestinal (ileal and jejunal), right colic, middle colic, and ileocolic arteries. Occlusion of this artery causes acute bowel ischemia

superior mesenteric

One complication of atrial fibrillation is a ___________ event that occurs as a result of a clot being expelled from the left atrium. This arterial clot may be manifested by signs of poor perfusion to the peripheral vascular system. The signs of acute clot include the "6 Ps": pain, pallor, paresthesias, paralysis, pulselessness, and poikilothermia. The patient's clot needs to be urgently addressed to salvage the tissue distal to the site of arterial obstruction.

thromboembolic